Impact of Obesity on Treatment Approach for Resectable Esophageal Cancer

Background: With the prevalence of obesity and its known association with esophageal cancer, there is increasing need to understand how obesity affects treatment. Methods: Using The Society of Thoracic Surgeons General Thoracic Surgery Database, we retrospectively evaluated all patients who underwent esophagectomy with gastric conduit reconstruction between 2012 and 2016. Patients were categorized into five body mass index groups. Associations between body mass index and surgical technique, resection, lymphadenectomy, staging, and neoadjuvant treatment were evaluated using multivariable logistic regression models. Results: In all, 8547 patients were included in the analysis. Obese and morbidly obese patients were more likely to undergo open procedures compared with normal-weight patients (odds ratio [OR] 1.18, P =.016; and OR 1.45, P =.007), with longer operative times. Morbidly obese patients had a higher rate of intraoperative conversion from minimally invasive to open approaches (OR 3.75, P =.001). There were no differences in R0 resection or lymphadenectomy, and staging workup was similar. Obese patients were less likely to receive neoadjuvant therapy (OR 0.75, P =.048), and overweight and obese patients were less likely to receive preoperative radiation (OR 0.75, P =.017; and OR 0.71, P =.010). Analyzing by stage, overweight and obese patients with cT2N0 disease were less likely to receive neoadjuvant treatment (OR 0.54, P =.016; and OR 0.37, P <.001). There were no differences in neoadjuvant therapy for cT3 or node-positive disease. Conclusions: Higher body mass index is associated with increased use of open versus minimally invasive esophagectomy and intraoperative conversion. Whereas staging workup and oncologic outcomes of surgery are similar, overweight and obese patients with cT2N0 disease are less likely to undergo neoadjuvant treatments.